Nz Superannuation Application Form - PDF by qqs20207

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									                                                                      The SuperGold Card                                             Accepted forms of identification                                        Column B document from:                                           Column A documents                  Column B document from:
                                                                      The SuperGold Card is a discounts and concessions card         When applying for a SuperGold Card you will need to provide               G
                                                                                                                                                                                                             •		 overnment	organisations	     •		 n	employer,	past	or	
                                                                                                                                                                                                                                                A                                 P
                                                                                                                                                                                                                                                                                •		 hoto	page	of	current	          •		 overnment	
                                                                                                                                                                                                                                                                                                                     G
                                                                                                                                                                                                               other than Work and              present eg a letter or pay        New Zealand Passport               organisations other than




                                                                                                                                                                                                                                                                                                                                                  APPLYING FOR A SUPERGOLD CARD
                                                                      issued free to all eligible New Zealanders who are aged        the following identification from the table below:
                                                                      65 years or over, and those aged under 65 years receiving                                                                                Income eg firearms               slip from employer                P
                                                                                                                                                                                                                                                                                •		 hoto	page	of	passport	           Work and Income e.g.
                                                                                                                                     •	 one	document	from	column	A	and
                                                                      New Zealand Superannuation or the Veteran’s Pension.                                                                                     licence, driver licence,       •		 ank	or	insurance	
                                                                                                                                                                                                                                                B                                 from another country               firearms licence, driver
                                                                                                                                     •	 one	document	from	column	B	(if	photo	identification	is	                Inland	Revenue                                                                                        licence,	Inland	Revenue
                                                                      This card recognises the valued contribution our seniors                                                                                                                  company eg a record of            (along with the pages
                                                                                                                                        provided) or
                                                                      and veterans have made, and continue to make, to                                                                                       •		 n	expired	New	Zealand	
                                                                                                                                                                                                               A                                bank account transactions         showing your current               A
                                                                                                                                                                                                                                                                                                                   •		 n	expired	New	Zealand	
                                                                                                                                     •	 two	documents	from	column	B	(if	no	photo	identification	
                                                                      New Zealand society.                                                                                                                     passport provided it has         C
                                                                                                                                                                                                                                              •		 ommunity,	health	or	            residency status in New            passport provided it has
                                                                                                                                        is provided)
                                                                                                                                                                                                               an	expiry	date	that	is	no	       education organisation eg         Zealand)                           an	expiry	date	that	is	no	
                                                                      It gives cardholders access to a wide range of business        One of these documents must show that you have been known                 more than 5 years ago            school leaving certificate,       F
                                                                                                                                                                                                                                                                                •		 ull	New	Zealand	Birth	           more than 5 years ago
                                                                      discounts and will facilitate easy access to government        by this identity for at least two years (e.g. driver licence that was
                                                                      entitlements and local council concessions.                                                                                            •		 n	overseas	Birth	
                                                                                                                                                                                                               A                                HANZ 18+ card                     Certificate                        A
                                                                                                                                                                                                                                                                                                                   •		 n	overseas	Birth	
                                                                                                                                     issued more than two years ago or a letter from a prominent
                                                                                                                                                                                                               Certificate                    •		 rominent	community	
                                                                                                                                                                                                                                                P                                 C
                                                                                                                                                                                                                                                                                •		 ertificate	of	Date	of	Birth	     Certificate
                                                                      It also replaces both the Community Services Card and          community member such as a local doctor stating they have
                                                                      NZ Super Card issued to New Zealand Superannuation             know you as, “John Smith” for at least the last two years).             •		 	supplier	of	goods	or	
                                                                                                                                                                                                               A                                member; eg reference              (must have been issued             A
                                                                                                                                                                                                                                                                                                                   •		 	supplier	of	goods	or	
                                                                      and Veteran’s Pension recipients. The back of the new card                                                                               services eg a telephone or       from Justice of the Peace,        prior to September 1995)           services eg a telephone
                                                                      clearly indicates whether a cardholder has entitlement to      Column A documents                                                        power account                    doctor, kaumatua.                 W
                                                                                                                                                                                                                                                                                •		 hakapapa	(for	clients	           or power account
                                                                      New Zealand Superannuation, the Veteran’s Pension              •		 hoto	page	of	current	New	
                                                                                                                                       P                                 •		 onfirmation	of	Permanent	
                                                                                                                                                                           C                                                                                                      not registered at birth or         A
                                                                                                                                                                                                                                                                                                                   •		 n	employer,	past	or	
                                                                      and/or a Community Services Card. This means these                                                                                     Please note we require original or ‘certified copies’ of your        who cannot be located              present eg a letter or pay
                                                                                                                                       Zealand Passport                    Residence,	letter	from	the	
                                                                      two other cards are no longer needed.                                                                                                  identification to accompany all card applications.’ Certified        on the birth register)             slip from employer
                                                                                                                                     •		 hoto	page	of	passport	
                                                                                                                                       P                                   New Zealand immigration
                                                                                                                                                                                                             copies’ means the original copy was copied, stamped and
                                                                      There are two versions of the card; an “S-branded”               from another country                Service                                                                                                C
                                                                                                                                                                                                                                                                                •		 ertificate	of	Registration,	     B
                                                                                                                                                                                                                                                                                                                   •		 ank	or	insurance	
                                                                                                                                                                                                             initialed either by a Work and Income staff member, Justice
                                                                      SuperGold Card and a special “V-branded” Veteran                 (along with the pages               C
                                                                                                                                                                         •		 ertificate	of	Identity                                                                               Naturalisation,                    company eg a record
                                                                                                                                                                                                             of	the	Peace,	Police	Officer,	Solicitor	or	Court	Registrar.
                                                                      SuperGold Card.                                                  showing your current                A
                                                                                                                                                                         •		 pplication	for	Refugee	                                                                              Citizenship	or	Refugee	            of bank account
                                                                                                                                                                                                             If you need help filling in the form or you do not have any of       Status                             transactions
                                                                                                                                       residency status in New             Status
                                                                      Veteran SuperGold Card                                                                                                                 the documents asked for, please visit your nearest Work and
                                                                                                                                       Zealand)                                                                                                                                   C
                                                                                                                                                                                                                                                                                •		 onfirmation	of	                  C
                                                                                                                                                                                                                                                                                                                   •		 ommunity,	health	or	
                                                                                                                                                                           F
                                                                                                                                                                         •		 or	Australian	born	             Income Service Centre, contact us on 0800 25 45 65 or
                                                                      The Veteran SuperGold Card is a specially branded version        F
                                                                                                                                     •		 ull	New	Zealand	Birth	                                                                                                                   Permanent	Residence,	              education organisation
                                                                                                                                                                           clients;	full	Australian	Birth	   send an e-mail to: info@supergold.govt.nz
                                                                      of the SuperGold Card.                                           Certificate                                                                                                                                letter from the New                e.g. school leaving
                                                                                                                                                                           Certificate, Passport, or
                                                                      You are eligible for a Veteran SuperGold Card if you have      •		 ertificate	of	Date	of	Birth	
                                                                                                                                       C                                   Proof	of	Residence                Adding a photo to your card                                          Zealand immigration                certificate, HANZ 18+
                                                                      served in a recognised war, emergency, or peace-keeping                                                                                                                                                     Service                            card

SuperGold Card
                                                                                                                                       (must have been issued            •		 or	Cook	Island,	Tokelauan	
                                                                                                                                                                           F                                 You may choose to add a photo to your SuperGold Card.
                                                                      operation and are aged 65 years or over, or are under 65         prior to September 1995)                                                                                                                   C
                                                                                                                                                                                                                                                                                •		 ertificate	of	Identity           P
                                                                                                                                                                                                                                                                                                                   •		 rominent	community	
                                                                                                                                                                           and Niuean clients; full          This could be useful if you do not have a current form of
                                                                      years and in receipt of a Veterans Pension.                                                                                                                                                                                                    member; eg reference
                                                                                                                                     •		 hakapapa	(for	clients	not	
                                                                                                                                       W                                   Birth	Certificate,	Letter	of	     photo identification, such as a driver licence or passport.          A
                                                                                                                                                                                                                                                                                •		 pplication	for	Refugee	
                                                                                                                                                                                                                                                                                                                     from Justice of the Peace,

Application Form
                                                                      If you are eligible and would like to receive this card, you     registered at birth or who          Confirmation, Certificate                                                                              Status
                                                                                                                                                                                                             Your photo will be taken and a new card will be posted to                                               doctor, kaumatua.
                                                                      will need to provide us with your Service Number and the         cannot be located on the            of	Registration,	or	              you, free of charge.                                                 F
                                                                                                                                                                                                                                                                                •		 or	Australian	born	
                                                                      war, emergency, or peace-keeping operation(s) you were           birth register)                     Naturalisation.                                                                                        clients; full Australian
                                                                      deployed to.                                                                                                                           To arrange for a photo to be added to your card, visit your
                                                                                                                                     •		 ertificate	of	Registration,	
                                                                                                                                       C                                                                                                                                          Birth	Certificate,	Passport,	
                                                                                                                                                                                                             nearest	AA	Driver	and	Vehicle	Licensing	outlet	with	your	card.	
                                                                      We will verify this information with Veterans’ Affairs           Naturalisation, Citizenship                                                                                                                or	Proof	of	Residence
 The card that recognises the contribution our seniors and veterans   New Zealand when we process your application.                                                                                          Accepted forms of identification to add a photo to your
                                                                                                                                       or	Refugee	Status                                                                                                                          F
                                                                                                                                                                                                                                                                                •		 or	Cook	Island,	
 have made, and continue to make, to New Zealand society.                                                                                                                                                    SuperGold Card from the table below:
                                                                                                                                                                                                                                                                                  Tokelauan and Niuean
                                                                      Who will receive the card?                                                                                                             •	 one	document	from	column	A	and                                    clients;	full	Birth	
                                                                      The card will automatically be sent to all New Zealand                                                                                 •	 one	document	from	column	B	(if	photo	identification	is	           Certificate,	Letter	of	
                                                                      residents who receive New Zealand Superannuation or a                                                                                     provided) or                                                      Confirmation, Certificate
                                                                      Veteran’s Pension, or who are aged 65 years or over who                                                                                •	 two	documents	from	column	B	(if	no	photo	identification	          of	Registration,	or	
                                                                      receive some other form of assistance from the Ministry of                                                                                is provided)                                                      Naturalisation.
                                                                      Social Development.
                                                                      If you are 65 years or over and do not receive any of the
                                                                      above listed assistance, you will need to apply for a card.
                                                                      If you are unsure whether you need to apply for a card,
                                                                      contact the SuperGold Card Centre on 0800 25 45 65.
SuperGold Card Application Form                                                                                                                                                                                                                                                    Client Number

Please complete all sections
PERSONAL DETAILS

 Title            First	Name                                                                                 Middle Name/s                                                                                                                                                         Surname


 If you have ever been known by another name, please state                                                                           Gender                                                                                                                                         Date	of	Birth
                                                                                                                                                     Male                                                                          Female                                                                                                                                             /                                                                                                                 /

 Personal	IRD	Number                                                                    Phone Number                                                                                                                                                        Email Address


 What is your partner’s name?


 Address (If you live at a rural address, please include your rural delivery address)




 Do you have a different address for your mail?                                                                  Yes                         No
 If yes, please list below.


 Where were you born?                                                                              What is your residency status?
                                                                                                                             NZ Permanent                                                                                                                                                                                                                           Temporary
                                                                                                         NZ Citizen          Resident                                                                                                                                                                                                                               Visa                                                                                                                                                                      Refugee

 If you were not born in New Zealand you will need to provide certified copies of your New Zealand residence documents.
 When did you arrive in New Zealand?                                      Is New Zealand                                                                                             If you do not normally live in New Zealand, where do you live?
                                                                          where you
                  /                  /                                    normally live?                              Yes                        No

 Marital Status (tick one)
                                                                     De	Facto/
         Single            Married                                   Relationship	                            Civil Union                            Widowed                                                                                            Divorced                                                                                                                   Separated or                                                                                                                                                                   Civil Union
                                                                     like Marriage                                                                                                                                                                                                                                                                                                 Living	Apart                                                                                                                                                                   Dissolved

 Have you served in the New Zealand                                                                                   If yes, please state:
 Armed	Forces	in	a	war,	emergency,	                                                                                   The war, emergency, or peace-keeping operation(s) you were deployed to?
 or peace-keeping operation?
                                                                         Yes                      No

                                                                                                                                                                                                                                                                                                                                                                                                    Merchant Navy
 The service(s) you served with (Tick those that apply)                                                                Navy                                                                                        Army                                                  Airforce                                                                                                                   – WWII
 Your Service Number(s)



 I confirm that the above information is true and correct.
 Signature                                                                                                                                                                                                                                  Date                                                                                                                                      /                                                                                                                 /


AGENT/POWER OF ATTORNEY


 Have you completed this form for someone else?                                                                 Yes                  No
 If ‘Yes’, you will need to complete an Appointment of an Agent Authorisation form which is available at your local Work and Income
 Service Centre.
 Please	note,	this	is	not	a	New	Zealand	Superannuation	Form.

 Privacy Statement
 Where you voluntarily provide personal information, we will only use that information for the purposes of the legislation administered by the Ministry of Social Development. We
 will keep any such information secure. To view any personal information held by us, or if you have any concerns about personal information that we hold and wish to request its
 correction,	you	can	email	us	or	write	to	us	at:	The	Chief	Executive,	Ministry	of	Social	Development,	PO	Box	1556,	Wellington,	New	Zealand.
 If you have any questions about the SuperGold Card please call us on 0800 25 45 65.
 Please	return	your	completed	form	to	your	nearest	Work	and	Income	Service	Centre	or	post	to:	The	SuperGold	Card	Centre,	PO	Box	5054,	Wellington	6145.
                                                                                                                                                                                                                                                Email:
                                                                                                                                                                                                                                 Write to us:
                                                                                                                                                                                                                                                                                                                                                                    Our contacts




                                                                                                                                     Your new card




                               Cardholder name
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              Conditions of use




                                                                                                                        Card front
                                                                                                                                                                                                                   PO Box 5054
                                                                                                                                                                                                                                                                         Freephone:	 0800 25 45 65




                                                                                                                                                                                                                   WELLINGTON 6145
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           Ordering a replacement card




                                                                                                                                                                                                                   SuperGold Card Centre
                                                                                                                                                                                                                                                info@supergold.govt.nz
                                                                                                                                                                                                                                                                                                                                                                                    •	 cannot	give	your	card	away,	lend,	assign,	or	pledge	it
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                    Your SuperGold Card is a personal card. This means you:




                                                                                                                                                                                                                                                                                                     For	more	information	about	the	SuperGold	Card	contact	us	at:




                                                                                                                                                      Or visit our SuperGold Card website: www.supergold.govt.nz




                                                                                                 Card back




                             Card and client numbers
                                                                                                                                                                                                                                                                                                                                                                                    •	 must	present	this	card	to	obtain	any	of	its	permitted	discounts	and	concessions

                                                                                                                                                                                                                                                                                                                                                                                    •	 cannot	use	your	card	if	we	have	asked	you	to	send	it	back	and/or	have	sent	you	a	new	card.




                                                                                      expiry	dates




                                                       validation/	expiry	dates
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      a	new	card	on	0800	25	45	65	or	send	an	email	to:	info@supergold.govt.nz.	You	do	not	need	to	fill	out	this	Application	Form.




                                                       entitlement notations and
                                                       Community Services Card
                                                       Cardholder	signature	box
                                                                                      client number & Community
                                                                                      Card magnetic strip contains




                                                       NZ Super/ Veteran’s Pension/
                                                                                      cardholder name, card number,

                                                                                      Services Card commencement &
                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                      Should your SuperGold Card become lost or stolen, or if you change your name, you can contact the SuperGold Card Centre to request

								
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